Healthcare Provider Details

I. General information

NPI: 1629304183
Provider Name (Legal Business Name): BAYOU PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 PADGETT SWITCH RD
IRVINGTON AL
36544-4015
US

IV. Provider business mailing address

PO BOX 129
GRAND BAY AL
36541-0129
US

V. Phone/Fax

Practice location:
  • Phone: 251-824-7979
  • Fax: 251-824-7989
Mailing address:
  • Phone: 251-865-1040
  • Fax: 251-865-1041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number113326
License Number StateAL

VIII. Authorized Official

Name: CHARLES COTTRELL
Title or Position: PRESIDENT/PHARMACIST
Credential:
Phone: 251-824-7979